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NSW Institute of Trauma and Injury Management
Trauma ‘Code Crimson’ Pathway Streamlining access to definitive intervention
for patients with life-threatening haemorrhage
NSW ITIM – Trauma ‘Code Crimson’ Pathway i
AGENCY FOR CLINICAL INNOVATION
Level 4, Sage Building
67 Albert Avenue
Chatswood NSW 2067
PO Box 699 Chatswood NSW 2057
T +61 2 9464 4666 | F +61 2 9464 4728
E [email protected] | www.aci.health.nsw.gov.au
SHPN (ACI) 170038, ISBN 978-1-76000-595-5.
Produced by: NSW Institute of Trauma and Injury Management
Further copies of this publication can be obtained from the Agency for Clinical Innovation website at
www.aci.health.nsw.gov.au
Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be
reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source.
It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above
requires written permission from the Agency for Clinical Innovation.
Version: 1 Trim: ACI/D16/5778
© Agency for Clinical Innovation 2017
The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to
design and promote better healthcare for NSW. It does this by:
service redesign and evaluation – applying redesign methodology to assist healthcare
providers and consumers to review and improve the quality, effectiveness and efficiency
of services
specialist advice on healthcare innovation – advising on the development, evaluation and
adoption of healthcare innovations from optimal use through to disinvestment
initiatives including guidelines and models of care – developing a range of evidence-based
healthcare improvement initiatives to benefit the NSW health system
implementation support – working with ACI Networks, consumers and healthcare providers
to assist delivery of healthcare innovations into practice across metropolitan and rural NSW
knowledge sharing – partnering with healthcare providers to support collaboration, learning
capability and knowledge sharing on healthcare innovation and improvement
continuous capability building – working with healthcare providers to build capability
in redesign, project management and change management through the Centre for
Healthcare Redesign
ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to
collaborate across clinical specialties and regional and service boundaries to develop
successful healthcare innovations.
A priority for the ACI is identifying unwarranted variation in clinical practice and working in
partnership with healthcare providers to develop mechanisms to improve clinical practice
and patient care.
www.aci.health.nsw.gov.au
NSW ITIM – Trauma ‘Code Crimson’ Pathway ii
Acknowledgements
NSW Institute of Trauma and Injury Management
Ms Kelly Dee, Clinical Review Officer
Dr Michael Dinh, Clinical Director
Mr Benjamin Hall, Project Officer
Ms Christine Lassen, Manager
Mr Elvis Maio, Data Manager
Dr Pooria Sarrami, Research Officer
Mr Hardeep Singh, A/Data Manager
Mr Glenn Sisson, Project Officer
Institute of Trauma and Injury Management, Clinical Review Committee
Ms Louise Alderson, Paramedic Trauma Advisor, NSW Ambulance Service
Ms Kay Best, Paediatric Trauma CNC, The Children's Hospital at Westmead
Dr Scott D’Amours - Co-Chair, Trauma Director, Liverpool Hospital
Dr Ailene Fitzgerald, Trauma Director, The Canberra Hospital, ACT
Dr Toby Fogg, Medical Director, CareFlight
Dr Tony Grabbs, Trauma Director, St Vincent’s Hospital
Dr Karel Habig, Medical Director, HEMS, NSW Ambulance Service
Dr Jeremy Hsu - Chair, Trauma Director, Westmead Hospital
Dr Sean Kelly, Clinical Director, Intensive Care and Coordination Monitoring Unit
Ms Kate King, Trauma CNC, John Hunter Hospital
Dr Timothy Lyons, Clinical Director, Forensic Medicine, Hunter New England Health Service
Ms Maryanne Sewell, Trauma CNC, Northern NSW Local Health District
Other Acknowledgements
Thanks to Dr Oran Rigby, Ms Kellie Wilson, and Dr Tony Joseph for their previous input into this
document.
NSW ITIM – Trauma ‘Code Crimson’ Pathway 1
Abbreviations
ACI Agency for Clinical Innovation
AMRS Aeromedical and Medical Retrieval Services
CRC Clinical Review Committee
CT Computed Tomography
ED Emergency Department
E-FAST Extended Focussed Assessment with Sonography for Trauma
ETA Estimated Time of Arrival
ETT Endotracheal Tube
HEMS Helicopter Emergency Medical Services
IIMS Incident Information Management System
IMIST Identification, Mechanism, Injury, Signs, Treatment and trends
IRS Interventional Radiology Suite
ITIM Institute of Trauma and Injury Management
KPI Key Performance Indicator
MTP Massive Transfusion Protocol
OT Operating Theatre
RBC Red Blood Cells
RCA Root Cause Analysis
NSW ITIM – Trauma ‘Code Crimson’ Pathway 2
1. Introduction
Background
Small subsets of severely injured trauma patients require time-critical surgical or interventional
radiological procedures to arrest life-threatening non-compressible haemorrhage following blunt or
penetrating trauma. Designated trauma centres around NSW have a range of policies, procedures
and guidelines and appropriate facilities for the management of patients with exsanguinating
haemorrhage. It has been observed through the Institute of Trauma and Injury Management (ITIM)
Clinical Review Committee (CRC) that inconsistent application of these policies, procedures and
guidelines (especially after-hours) may contribute to delays to definitive surgical or interventional
radiological procedures. A range of Incident Information Management System (IIMS) case reports,
Root Cause Analyses (RCAs) and sentinel event investigations have identified that intra-hospital
delays to definitive intervention continue to occur and directly impact survival in the small subset of
patients with uncontrolled non-compressible haemorrhage.
Emergency department (ED) diversion is a technique used in trauma management around the
world to streamline access to definitive intervention. Contemporary military trauma systems as
well as the Helicopter Emergency Medical Services (HEMS) in Europe and the United Kingdom all
practice ED diversion where the patient would benefit from immediate transfer to the Operating
Theatre (OT) or Interventional Radiology Suite (IRS), such as in cases of life-threatening
haemorrhage and isolated severe brain injury.
In NSW, the physician-based Aeromedical and Medical Retrieval Services (AMRS) have the
capability to perform a large range of procedures on-scene, en-route and in referring hospitals,
which are traditionally performed by ED based trauma teams in the resuscitation of trauma patients
including:
Pre-hospital emergency anaesthesia and tracheal intubation
Surgical thoracostomy (simple or tube)
Pelvic and long bone fracture splinting
Application of tourniquets
Maxillo-facial haemorrhage control
Administration of red blood cells
Advanced surgical procedures such as clamshell thoracotomy, resuscitative hysterotomy,
lateral canthotomy and surgical airways
Extended Focussed Assessment with Sonography for Trauma (E-FAST) examination to
detect pneumothoraces, or significant free intra-peritoneal, pericardial or intra-thoracic
haemorrhage.
Patients who remain persistently haemodynamically unstable due to on-going haemorrhage
despite such interventions are very unlikely to benefit from prolonged time spent in ED
resuscitation areas. A process for expediting transfer to definitive intervention in the Operating
Theatre or Interventional Radiology Suite may be lifesaving in such cases.
NSW ITIM – Trauma ‘Code Crimson’ Pathway 3
Definition
‘Code Crimson’ is a term that has commonly been used by hospital-based teams managing
patients with life-threatening haemorrhage that is refractory to resuscitation. The purpose of a
‘Code Crimson’ is to streamline this patient’s access to definitive intervention, including an
operating theatre or interventional radiology suite.
Aim
This guideline seeks to enhance the current management of a patient with life-threatening
traumatic haemorrhage by recommending that pre-hospital medical retrieval teams initiate a ‘Code
Crimson’ activation, thereby further reducing the time to definitive intervention in these patients.
This clinical guideline therefore aims to standardise the:
pre-hospital identification of a trauma ‘Code Crimson’.
activation of a trauma ‘Code Crimson’ pathway by pre-hospital medical retrieval teams and
the subsequent notification to a receiving trauma centre.
procedures instituted by trauma centres following activation of a trauma ‘Code Crimson’
pathway.
Scope
This guideline is intended for use by Aeromedical and Medical Retrieval Services and ED clinicians
in Major Adult and Paediatric Trauma Services managing patients with life-threatening traumatic
haemorrhage refractory to pre-hospital resuscitation. Whilst it is acknowledged that some hospitals
are not in a position to fulfil the requirements of this document, its use in Regional Trauma
Services is encouraged and supported.
This guideline provides recommendations on the pre-hospital activation of a trauma ‘Code
Crimson’ pathway and subsequent procedures instituted in the ED following activation. It is
recognised that the recommendations may not suit all patients in all clinical settings and should not
replace clinical judgement. This guideline relies on individual clinicians to decipher the needs of
individual patients.
NSW ITIM – Trauma ‘Code Crimson’ Pathway 4
2. Trauma ‘Code Crimson’ Pathway
The trauma ‘Code Crimson’ pathway:
1. identifies exsanguinating trauma patients in the pre-hospital environment who would benefit
from rapid transfer to definitive interventional care area of a trauma centre, when there is
likely to be minimal benefit from time spent in ED resuscitation areas.
2. outlines the process for pre-hospital medical retrieval teams (physician with paramedic) to
activate ‘Code Crimson’ pathways in trauma centres, in order to facilitate early transfer to
definitive interventional care.
3. outlines the required actions by the receiving trauma centre when the ‘Code Crimson’
pathway is activated by the pre-hospital medical team (physician with paramedic).
Objective
For trauma patients who are bleeding despite pre-hospital resuscitation by medical teams
(physician with paramedic), and requiring time-critical life-saving intervention, to be rapidly
transferred to definitive intervention.
Criteria for Activation
Clinical examples of potential injuries meeting the above criteria:
Blunt trauma Penetrating trauma
Abdominal trauma with grossly positive E-
FAST
Uncontrolled maxillo-facial haemorrhage
Gross pelvic disruption
Massive haemothorax
Traumatic amputation
Penetrating trauma to chest/abdomen
Junctional penetrating trauma
Pericardial tamponade on E-FAST
Penetrating neck wounds with hard signs of
vascular injury
Standard trauma care
Clinical issues to address irrespective of pre-hospital activation of trauma ‘Code Crimson’:
1. Airway: Patent and protected – patient alert or endotracheal tube insitu (confirmed with
continuous waveform capnography)
2. Breathing: Significant pneumothorax excluded with pre-hospital ultrasound or definitive
thoracic decompression performed (surgical thoracostomy)
3. Circulation: Pelvic binder in place, long bone fractures appropriately splinted and external
haemorrhage treated (where feasible)
Persistent haemodynamic instability despite standard trauma care (see below),
assessed as being secondary to ongoing haemorrhage in blunt or penetrating trauma,
which is unresponsive to intravenous fluids and or blood transfusion.
NSW ITIM – Trauma ‘Code Crimson’ Pathway 5
Aeromedical and Medical Retrieval Service activation procedure
The following points outline the recommended procedure for the pre-hospital activation of the
Trauma ‘Code Crimson’ Pathway by the medical retrieval team:
Trauma notification (“Bat phone”) call to be made as soon practicable from the medical
retrieval team to the receiving ED identifying “pre-hospital activation of trauma ‘Code
Crimson’”
Notification to be given in the Identification, Mechanism, Injury, Signs, Treatment and
trends (IMIST) format including an expected time of arrival (ETA)
If the source of the haemorrhage is clear (for example, positive E-FAST, massive
haemothorax external haemorrhage) this information should be passed on as part of the
initial IMIST
Provide the receiving hospital with an updated ETA closer to arrival where indicated
Early pre-hospital activation is essential to allow the trauma centre to assemble the trauma team
and any other required specialty staff in OT or IRS and to activate a massive transfusion protocol
(MTP).
Trauma centre procedure following activation
The following points outline the recommended procedures for a trauma centre once they have
received a pre-hospital activation of the Trauma ‘Code Crimson’ Pathway from a medical retrieval
team.
ED confirms “pre-hospital activation of trauma ‘Code Crimson’”
Document IMIST notification from the medical retrieval team
Activate Trauma Team (for example: “Trauma Attend”)
o Surgical Consultant or Fellow on for Trauma notified by phone; respond immediately
o Relevant subspecialty Surgical Consultant or Fellow notified
o Radiographer notified and present in resuscitation room
Confirm OT / IRS room and staff availability - mobilise additional teams if not available
Inform Blood Bank of ‘Code Crimson’ – activate Massive Transfusion Protocol (MTP):
o Blood products to be available immediately in resuscitation room and or helipad
o Blood Bank to prepare additional blood products e.g. uncrossmatched plasma,
cryoprecipitate
o Fluid warmer and or rapid infuser primed with blood in ED
Trauma Team reception in ED – critical decision point
Handover and initial trauma assessment (primary survey) in ED
Rapid decision (<10 minutes) made by Surgical Consultant or Fellow +/- Trauma
Consultant or Fellow for disposition to Operating Theatre (OT), Interventional Radiology
Suite (IRS), Hybrid Angiography Suite or Computed Tomography (CT)
NSW ITIM – Trauma ‘Code Crimson’ Pathway 6
3. Algorithm 1: Pre-hospital Activation of Trauma ‘Code
Crimson’ by the Medical Retrieval Team
Persistent haemodynamic instability despite standard trauma care*,
assessed as being secondary to ongoing haemorrhage in blunt or penetrating trauma
Unresponsive to intravenous fluids
and or blood transfusion
* Standard trauma care (irrespective of activation)
Assess and manage the patient as per trauma policies and procedures including:
Airway patent and protected (patient alert or endotracheal tube insitu)
Significant pneumothorax excluded or managed
Pelvic and limb fractures excluded or splinted
External haemorrhage treated (where feasible)
Does not meet pre-hospital
trauma ‘Code Crimson’
activation criteria
Continue to re-assess and manage*
Meets pre-hospital trauma ‘Code Crimson’ activation criteria
Continue providing standard trauma care*
Notify receiving hospital ED as soon as practicable via “Batphone”
Clearly identify “pre-hospital activation of trauma ‘Code Crimson’”
Provide pre-hospital notification in IMIST format including estimated time of arrival and
probable source of haemorrhage
Yes
Yes
No
NSW ITIM – Trauma ‘Code Crimson’ Pathway 7
4. Algorithm 2: Trauma Centre ED Response to Pre-hospital Activation of Trauma ‘Code Crimson’
Trauma ‘Code Crimson’ activated by pre-hospital medical retrieval team
ED to confirm “pre-hospital activation of trauma ‘Code Crimson’ ”
Document pre-hospital notification from retrieval team in IMIST format
Activate trauma team – for example, “Trauma Attend”
Notify Surgical Consultant / Fellow on for Trauma via phone – immediate response required
Notify other relevant subspecialty surgical Consultant / Fellow
Notify Radiographer – to be present in resuscitation room
Notify blood bank – activate Massive Transfusion Protocol
2 units uncrossmatched Red Blood Cells to be available immediately in ED and or helipad
Blood Bank to thaw and supply uncrossmatched Fresh Frozen Plasma
ED fluid warmer and or rapid infuser primed with blood
Trauma Team reception of patient in ED
Handover and initial assessment (primary survey)
Rapid decision (<10 minutes) for disposition
Surgical Consultant or Fellow +/- Trauma Consultant to decide:
Operating Theatre / Interventional Radiology / Computer Tomography
Confirm Operating Theatre / Interventional Radiology room and staff availability
Mobilise additional theatre / radiology team if necessary
Mobilise
NSW ITIM – Trauma ‘Code Crimson’ Pathway 8
5. Ongoing evaluation of pathway
All cases involving the Trauma ‘Code Crimson’ Pathway being activated should be reviewed
locally, as per usual processes. It is recommended that the local review covers the patient
assessment, interventions performed, and whether the recommended Key Performance Indicators
(KPIs) were met.
All cases should be notified to the ITIM Clinical Review Officer for de-identified case review at the
ITIM Clinical Review Committee. ITIM will provide six-monthly feedback to all stakeholders to
inform the clinical guideline.
Recommended Key Performance Indicators or Outcome Measures
The following KPIs or outcome measures are recommended to be part of individual service’s
ongoing evaluation of the pathway:
Trauma ‘Code Crimson’ Pathway is activated by a medical retrieval team according to the
criteria
The disposition of a patient fitting the criteria for Trauma ‘Code Crimson’ Pathway activation
is determined within 10 minutes of review by the receiving hospital trauma team.
A patient fitting the criteria for Trauma ‘Code Crimson’ Pathway activation is transferred to
the Operating Theatre and or Interventional Radiology Suite within 30 minutes of review by
the receiving hospital trauma team.
Other trauma process indicators as outlined in the NSW ITIM Trauma Process Indicators
webpage: https://www.aci.health.nsw.gov.au/networks/itim/Data/nsw-trauma-process-
indicators
NSW ITIM – Trauma ‘Code Crimson’ Pathway 9
6. Bibliography
Eastern Association for the Surgery of Trauma (2010) Triage of the Trauma patient.
https://www.east.org/education/practice-management-guidelines/triage-of-the-trauma-patient
Grabs, A., M. AN, et al. (2008). "Code Crimson: a life-saving measure to treat exsanguinating
emergencies in trauma." ANZ J Surg 78(7): 523-525.
Reed, M., A. Glover, et al. (2017). "Experience of implementing a National pre-hospital Code Red
bleeding protocol in Scotland." Injury 48(1): 41-46.
Tai, N. and R. Russell (2011). "Right turn resuscitation: frequently asked questions." J R Army Med
Corps 157(3 Suppl 1): S310-314.
Tinkoff, G. and R. O'Connor (2002). "Validation of new trauma triage rules for trauma attending
response to the emergency department." J Trauma 52(6): 1153-1158; discussion 1158-1159.
Weaver, A., C. Hunter-Dunn, et al. (2016). "The effectiveness of Code Red transfusion request
policy activated by pre-hospital physicians." Injury 47(1): 3-6.